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Inspection Summary

Overall summary & rating


Updated 17 October 2017

This inspection took place on 1 September 2017 and was unannounced.

Letheringsett Hall provides accommodation and care for up to 20 older people. At the time of this inspection 17 people were living in the home.

Our previous inspection in July 2016 identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to implementation of the Mental Capacity Act 2005 and the governance of the service. This September 2017 inspection found that improvements had been made in both of these areas and that the provider was no longer in breach of these regulations.

The provider was one of the two registered managers for the service. However, the registered manager who managed the service on a day to day basis had left five weeks prior to this inspection. A new manager had been appointed. They told us that they would be applying for registration. In the meantime the provider was at the service on a daily basis managing the home and overseeing the transition to the new manager.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People felt safe living in the home and were cared for by staff that treated them considerately and with respect. There were enough staff to meet people’s needs and provide them with caring, prompt and effective support. People’s medicines were managed safely and administered as prescribed for them.

Assessments of people’s ability to make decisions about their care had been completed and appropriate applications were made to the local authority’s DoLS team when required. People’s independence was supported without their safety being compromised. People’s healthcare needs were managed well and people had access to a range of healthcare professionals. The service regularly sought the views of people about the standard of service that they received.

People liked the food and the service sought to provide as much homemade food as possible. Staff were trained and well supported to undertake their duties.

The home was well led and worked effectively with healthcare professionals. People knew the provider and the manager well. A smooth transition to the new manager was underway.

Inspection areas



Updated 17 October 2017

The service was safe.

Risk to people�s welfare were identified and plans were in place to reduce risks as far as was possible.

People received their medicines as prescribed for them.

There were enough staff to meet people�s needs. Recruitment systems were in place, however on one occasion these had not been followed.



Updated 17 October 2017

The service was effective.

Improvements had been made to ensure that the service operated in accordance with the Mental Capacity Act 2005.

People were looked after by staff who had received the necessary training to support and care for them effectively.

Arrangements were in place to support people with their health needs.



Updated 17 October 2017

The service was caring.

Staff were positive about the staff that supported them.

Staff were friendly, patient and respectful.

People, and their relatives when appropriate, were involved in deciding what care was provided.



Updated 17 October 2017

The service was responsive.

Care planning was person-centred and people's individual choices and preferences supported.

Staff had a good understanding of people's needs and preferences.

There was a complaints system in place and people knew how to make a complaint.



Updated 17 October 2017

The service was well led.

Improvements had been made to the governance of the home.

The provider had ensured that a smooth transition was underway to the new manager.